Efficacy of mTOR Inhibitors and Intravenous Immunoglobulin for Treatment of Polyoma BK Nephropathy in Kidney Transplant Recipients: A Biopsy-Proven Study.

OBJECTIVES: We investigated the efficacy of a predetermined protocol that consisted of immunosuppressive drug reduction/withdrawal and intravenous immunoglobulin administration for the treatment of polyoma BK virus nephropathy. MATERIALS AND METHODS: Patients with biopsy-proven polyoma BK virus nephropathy received a treatment regimen based on discontinuation of both calcineurin inhibitors and antiproliferative agents and switching to mTOR inhibitors accompanied by intravenous immunoglobulin administration. RESULTS: Our study included 508 patients, with polyoma BK viremia detected in 80 patients. The mean age was 45.3 ± 9.5 years (range, 18-71 y), 64% were male, and mean follow-up was 37 ± 21 months (6-94 mo). All 16 patients who developed polyoma BK virus nephropathy and 9 patients who had highgrade polyoma BK viremia without nephropathy received intravenous immunoglobulin treatment. Compared with patients with viremia, patients with polyoma BK virus nephropathy had significantly higher rates of graft loss due to rejection (18.8% vs 1.6%; P = .024) and all-cause graft loss (31.2% vs 6.3%; P = .014). Histopathologically, viral inclusion bodies disappeared and SV40 became negative after treatment in all 13 patients who underwent protocol biopsies. Unfortunately, histopathologically complete recovery without chronic tubular and interstitial tissue damage was achieved in only 4 patients after treatment. In addition, 3 patients lost their grafts due to acute antibody-mediated or mixed-type rejection (18.8%). CONCLUSIONS: In patients with polyoma BK virus nephropathy, clearance of viremia and SV40 should not be the sole outcomes to obtain. Aggressive reductions in maintenance immunosuppression and switching to double-drug therapy combined with high-dose intravenous immunoglobulin leads to high rates of graft loss/rejection and sequalae of chronic histological changes.

A Rare Reason for Severe Hypocalcemia Following Kidney Transplant: Denosumab Treatment.

Deviations of calcium, phosphate, parathyroid hormone, and vitamin D levels are the basis for the diagnosis of calcium-phosphate metabolism disorders. The plasma concentration of the biologically active form known as free calcium is regulated in a harmonious manner by its exchange in the bones and reabsorption by the kidneys. These steps take place under the control of parathyroid hormone and calcitriol. In the process of chronic kidney disease, the kidney cannot synthesize adequate calcitriol, and the resulting hypocalcemia and hyperphosphatemia cause the development of secondary hyperparathyroidism. Osteoporosis is a metabolic bone disease and is essentially the consequence of osteoclastogenesis-induced bone resorption that exceeds bone formation. Osteoporosis is common after kidney transplant. However, hypocalcemia following kidney transplant is rare. The hungry bone syndrome after parathyroidectomy is often responsible for this condition in the pretransplant period. Denosumab is a human monoclonal antibody developed against the receptor activator of nuclear factor kappa-B ligand (known as RANKL). Denosumab exerts an antiresorptive effect on bones by reducing differentiation into osteoclasts. It is an effective treatment option for osteoporosis in the general population. There is insufficient scientific data regarding the use of denosumab in kidney transplant patients. Here, we present the case of a kidney transplant recipient who developed severe hypocalcemia (serum calcium 4.7 mg/dL) after denosumab treatment for osteoporosis.

The Oncologic Safety of Sentinel Lymph Node Biopsy in Patients with Node-Positive Breast Cancer with Complete Response to Neoadjuvant Chemotherapy: A Single-Center Experience.

Objective: To evaluate the efficiency and safety of sentinel lymph node biopsy (SLNB) in patients with breast cancer with complete response to neoadjuvant chemotherapy (NAC). Methods: Ninety-two consecutive (T1-4 and N1-2) patients with breast cancer who had pathologic and/or clinical and radiologic axillary lymph node involvement were included. All patients received NAC. Patients with a clinical and radiologic complete response in the axilla after NAC underwent SLNB. Pathologic complete response (ypCR) was defined as the absence of residual invasive and in situ cancer, and near-complete response (ypNCR) represented in situ and/or ≤ 1 mm residual tumor in the breast and/or presence of malignant cell clusters (≤0.2 mm) and/or micrometastases (≤2.0 mm) in the axillary lymph nodes (ALN) (ypTis/T1mi, ypN0i+/pN1mi). Results: The mean age of the 92 patients was 49.6 ± 10.3 years and the mean follow-up was 34.0 ± 17.8 months. With respect to breast tumors, 23 (25.0%) patients had complete and 14 (15.2%) had a near-complete response to NAC. Complete response in ALN was obtained in 39 (42.4%) patients and near-complete in six (6.5%) patients. The overall survival of the 33 patients who achieved ypCR and ypNCR was 100% and the remaining 59 patients with partial or no response to NAC was 83.1% at a mean follow-up of 34 months (p=0.063). Conclusions: In this study, no event developed in cases with ypCR and ypNCR in the breast and axilla. The persistence of the same results in long-termfollow-ups may enable the use of ypNCR as a positive prognostic marker in addition to ypCR.

The level of the neudesin in type-2 diabetic patients and the relationship between the metabolic parameters and carotid intima-media thickness.

BACKGROUND: Neudesin is a protein that is secreted from adipose tissue and central nervous system and has a regulatory function on energy metabolism. Although the effect of this protein is shown in the experimental model of type-2 diabetes mellitus (type-2DM), its effect in humans is not clearly known. In this study, we aimed to evaluate the relationship between serum neudesin level and metabolic, anthropometric and cardiovascular parameters in newly diagnosed type-2DM patients (group 1). METHODS: Forty patients in each were included in our study for group 1 and for the control group (group 2), which consisted of age and sex-matched healthy subjects. Serum neudesin, hs-CRP, carotid intima media thickness (CIMT), Body Mass Index (BMI) and insulin resistance (HOMA-IR) levels were compared prospectively. RESULTS: Serum neudesin levels were significantly higher in diabetic patients than in the control group (type-2DM: 64.69±3.06 ng/mL, control: 55.52±5.48 ng/mL, P=0.004*). There was an independent relationship between serum neudesin and HOMA-IR and BMI. Although there is a correlation between serum neudesin and CIMT; this feature disappeared in the regression analysis. CONCLUSIONS: Serum neudesin increased in new diagnosis type-2DM patients. This increase seems to be related to obesity and insulin resistance. However, more extensive research is needed to clarify this issue.

The Importance of the Pathological Perspective in the Management of the Invasive Lobular Carcinoma.

Background: Invasive lobular carcinomas (ILC) account for 10-15% of all breast cancers and are the second most common histological form of breast cancer. They usually show a discohesive pattern of single cell infiltration, tend to be multifocal, and the tumor may not be accompanied by a stromal reaction. Because of these histological features, which are not common in other breast tumors, radiological detection of the tumor may be difficult, and its pathological evaluation in terms of size and spread is often problematic. The SSO-ASTRO guideline defines the negative surgical margin in breast-conserving surgeries as the absence of tumor detection on the ink. However, surgical margin assessment in invasive lobular carcinomas has not been much discussed from the pathological perspective. Methods: The study included 79 cases diagnosed with invasive lobular carcinoma by a Tru-cut biopsy where operated in our center between 2014 and 2021. Clinicopathological characteristics of the cases, results of an intraoperative frozen evaluation in cases that underwent conservative surgery, the necessity of re-excision and complementary mastectomy, and consistency in radiological and pathological response evaluation in cases receiving neoadjuvant treatment were questioned. Results: The tumor was multifocal in 37 (46.8%) cases and single tumor focus in 42 (53.2%) cases. When the entire patient population was evaluated, regardless of focality, mastectomy was performed in 27 patients (34.2%) and breast-conserving surgery (BCS) was performed in 52 patients (65.8%). Of the 52 patients who underwent BCS, 26 (50%) required an additional surgical procedure (cavity revision or completion mastectomy). There is a statistical relationship between tumor size and additional surgical intervention (p < 0.05). BCS was performed in 7 of 12 patients who were operated on after neoadjuvant treatment, but all of them were reoperated with the same or a second session and turned to mastectomy. Neoadjuvant treatment and the need for reoperation were statistically significant (p < 0.05). Additional surgical procedures were performed in 20 (44.4%) of 45 patients in BCS cases who did not receive neoadjuvant therapy. Conclusions: Diagnostic difficulties in the intraoperative frozen evaluation of invasive lobular carcinoma are due to the different histopathological patterns of the ILC. In our study, it was determined that large tumor size and neoadjuvant therapy increased the need for additional surgical procedures. It is thought that the pathological perspective is the determining factor in order to minimize the negative effects such as unsuccessful cosmesis, an additional surgical burden on the patient, and cost increase that may occur with additional surgical procedures; for this reason, new approaches should be discussed in the treatment planning of invasive lobular carcinoma cases.

Gastrointestinal Tract Metastases of Invasive Lobular Carcinoma of the Breast: An Immunohistochemical Survey Algorithm.

Invasive lobular carcinoma (ILC) accounts for almost 15% of all breast carcinomas. The potential of ILC to metastasize to the gastointestinal system is significantly greater than that of invasive ductal carcinoma. Gastric metastasis occurred in the ninth year of the follow-up in a patient who was operated on the right breast due to ILC. The patient was investigated for simultaneous masses in the stomach and colon, and a random mass was found in her right breast.

Kidney Transplantation From Infected Donors With Particular Emphasis on Multidrug-Resistant Organisms: A Single-Center Cohort Study.

OBJECTIVES: Prevention of sepsis-related organ dysfunction in septic donors is crucial. In this study, septic donors were followed-up based on donor Sequential Organ Failure Assessment criteria. MATERIALS AND METHODS: Between January 2014 and 2020 at our center, 29 primary kidney transplant recipients received organs from 20 septic donors. All donors received either pathogen-specific or broad-spectrum antibiotics at least 48 hours before procurement, and all recipients received similar treatment posttransplant for an average of 7 to 14 days. Donor eligibility was determined according to the sum of donor-Sequential Organ Failure Assessment scores obtained from 6 parameters: Pao2/Fio2 ratio; platelet count; serum bilirubin, creatinine, and lactate levels; and presence of hypotension. The cut-off value for bacteremic donor acceptance was below 12 points. RESULTS: Fever (≥38 °C) persisted in 5 donors in the last 24 hours before organ removal. However, in these 5 donors, the mean donor-Sequential Organ Failure Assessment score was 6.5 ± 1.1, mean arterial pressure was >70 mm Hg, and serum lactate levels were <2 mmol/L. Fifteen donors had systemic inflammatory response syndrome scores of ≤2 with corresponding donor-Sequential Organ Failure Assessment scores of 7.9 ± 1.2; none had systemic inflammatory response syndrome scores >3, which would have indicated severe organ failure. In 28 recipients (97%), no donor-related infections were observed in the perioperative first month and afterwards. CONCLUSIONS: Treatment of donors and recipients with a common protocol greatly reduced the risk of donor-induced infection transmission. In addition, we found the donor-Sequential Organ Failure Assessment criteria to be a helpful tool in predicting organ failure in infected donors.

Acute Allograft Pyelonephritis: Vague Symptoms, Indeterminate Laboratory Results, and the Necessity of Indication Biopsy.

OBJECTIVES: In this study, we examined the clinical and biochemical features of biopsy-proven acute pyelonephritis among 769 kidney transplant recipients. MATERIALS AND METHODS: This cohort study was performed between January 2003 and December 2019 at the University of Health Sciences (Izmir, Turkey). Acute pyelonephritis refers to urinary tract infection with acute graft dysfunction. All patients with suspected acute pyelonephritis underwent diagnostic biopsy and received antibiotic treatment for an average of 14 to 21 days. Patients with acute pyelonephritis (18/769, 2.3%) were categorized into groups of 9 patients each: group 1 developed acute pyelonephritis in the first 6 months, and group 2 developed acute pyelonephritis >6 months posttransplant. RESULTS: All patients in group 1 had acute graft dysfunction; only 2 (22%) were symptomatic. All patients recovered baseline graft function after treatment. Patients in group 2 had at least 2 laboratory findings that included leukocytosis, neutrophilia, and high C-reactive protein values. Six patients had urine culture positivity. Recurrent pyelonephritis occurred in 3 patients. Four patients had graft loss. Over the mean follow-up of 48.0 ± 28.4 months, 14 patients (78%) were alive with a functioning graft. CONCLUSIONS: Diagnostic biopsy is of great importance in patients with urinary tract infection accompanied by acute graft dysfunction in the first 6 months after transplant.

Outcomes of 6 Human Leukocyte Antigen-Mismatched Living Donor Kidney Transplant: A Study With Biopsy Amendment.

OBJECTIVES: In this study, we examined the graft and patient survival outcomes in patients with end-stage kidney disease who received 6 HLA-mismatched incompatible living donor kidney transplant. MATERIALS AND METHODS: Patients who underwent living donor kidney transplant between January 2010 and March 2020 were evaluated retrospectively. Group A included kidney transplant recipients with 6 HLA mismatches, and group B included kidney transplant recipients with 0 to 5 HLA mismatches. Patients with <1 year of follow-up were excluded. All rejection episodes were diagnosed via Tru-Cut biopsy and histopathological evaluation. RESULTS: There were 15 patients in group A and 176 patients in group B. The mean follow-up was 54.1 ± 30 months. The number of patients who underwent pretransplant immune desensitization and received tacrolimus-based triple maintenance immunosuppression therapy was significantly higher in group A. In group A, there were 13 acute rejections seen in 9 patients (81<); in group B, there were 67 acute rejections seen in 51 patients (28.9<; P = .019). No differences were observed between the groups in terms of baseline glomerular filtration rate (60 ± 16 vs 61.6 ± 20 mL/min/1.72 m2; P = .76), final control glomerular filtration rate (60.7 ± 15 vs 58 ± 19 mL/ min/1.72 m2; P = .59), graft loss (0< vs 4<; P = .94), and mortality (6.6< vs 3<; P = .39). CONCLUSIONS: The presence of 6 HLA mismatches was associated with higher rates of biopsy-proven acute rejection. However, 6 HLA-mismatched incompatible living donor kidney transplant can be safely performed in centers where posttransplant followup is supported by indication and protocol biopsies and where there is a pathological infrastructure with extensive knowledge and experience.

Acute lower gastrointestinal bleeding due to low-grade mucinous neoplasm of appendix.

INTRODUCTION: Lower gastrointestinal tract (GIT) bleeding originating from the appendix is rare and may be difficult to diagnose. PATIENTS AND METHODS: In this case report, we present an 88-year-old male patient who was admitted with hematochezia due to appendiceal bleeding. A colonoscopy revealed bleeding in the appendix orifice so an appendectomy was performed, and bleeding did not recur in the postoperative period. RESULTS: The results of the microscopic examination showed low-grade mucinous neoplasm (LGMN) of the appendix. CONCLUSION: It should be kept in mind that bleeding may originate from the appendix in patients presenting with GIT bleeding. Our patient is the first to present with an acute lower GIT bleed who was diagnosed as having LGMN in the appendectomy specimen.

Breast cancer patients with isolated bone metastases and oligometastatic bone disease show different survival outcomes.

In this study, we planned to investigate the clinical course of patients with breast cancer with oligometastatic bone disease (OMBD). The patients were grouped according to the characteristics and the sites of metastases. Group I included 928 patients without metastasis. Group II, the OMBD group, included 68 patients. Group III, the widespread metastasis group, comprised 185 patients with multiple bone metastases and/or solid organ metastases. The mean overall survival of the groups was 16.7 ± 0.3 years in group 1, and 7.8 ± 0.8 and 5.9 ± 0.4 years in groups 2 and 3, respectively (p < 0.001 for the comparison of all three groups together; p < 0.001 for group 1 vs. 2 and 3) and (p = 0.037 for group 2 vs. group 3). In the subgroup survival analysis of patients in group 2 (OMBD), the mean and median survival was 5.5 ± 0.8 and 4.0 ± 0.8 years vs. 9.2 ± 0.98 and 9.0 ± 1.05 years in patients with more than one bone metastasis and single bone metastasis, respectively (p = 0.019). OMBD seems to be a different disease than breast cancer with isolated bone metastases. The high risk of developing OMBD, especially following locoregional recurrence, increases the importance of locoregional therapy in large T and N stage tumors.

COVID-19 pneumonia in kidney transplant recipients: A promising treatment algorithm in the absence of a disease-specific drug.

There is no consensus on the management of coronavirus disease 2019 (COVID-19) and modification of immunosuppressive therapy in kidney transplant recipients (KTRs). In this study, we examined the clinical outcome of our KTRs with COVID-19 disease, who were treated with a broad-spectrum anti-inflammatory protocol. This protocol is essentially composed of intravenous immunoglobulin +/- tocilizumab in KTRs with severe COVID-19 pneumonia. Among 809 KTRs, 64 patients diagnosed with COVID-19 disease between April 2020 and February 2021, were evaluated. Twenty-nine patients with pneumonia confirmed by chest computed tomography (CCT) were hospitalized. The treatment protocol included high-dose intravenous methylprednisolone, favipiravir, enoxaparin, and empirical antibiotics. Patients with pneumonic involvement of more than 25% on CCT with or without respiratory failure were given a total of 2 g/kg intravenous immunoglobulin (IVIg) therapy. Nonresponders received tocilizumab, an interleukin-6 receptor antibody. Of the 29 patients with pneumonia, 6 were treated in other hospitals. These six patients did not receive IVIg and 5 of them deceased. In our center, IVIg treatment was applied to 15 of 23 patients. Seven of them required tocilizumab. Respiratory parameters improved significantly in all but one patient after IVIg ± tocilizumab treatment. The mortality rate was 6.6% in patients who received IVIg therapy and 35.7% in those who did not (p = 0.08). The mortality rate was higher in patients who received treatment in external centers (2.2% vs. 26.3%; p = 0.0073). The treatment of KTRs with severe COVID-19 pneumonia in organ transplant centers with significant experience yields better results. The administration of broad-spectrum anti-inflammatory treatment in this patient group was safe and provided excellent outcomes.

The efficacy of interleukin-1 antagonist drugs in combination with colchicine in patients with FMF-AA with colchicine resistance after kidney transplantation: A study with histopathologic evidence.

BACKGROUND: The efficacy of anti-interleukin-1 (IL-1) drugs in kidney transplant patients with FMF-AA who developed colchicine resistance has not been clearly demonstrated. METHOD: Thirty nine kidney transplant recipients with FMF-AA were evaluated. Group 1 consisted of patients who were in remission after transplantation with colchine and Group 2 included those who developed colchicine resistance. RESULTS: The mean follow-up of the patients was 88.5 ± 61.9 months. Following the treatment with IL-1 antagonists; serum Amyloid A (SAA) averages (79.4 ± 35.3 mg/L) as well as the average number of hospitalizations per month due to FMF episodes (1.4 ± 0.5 times/month) decreased significantly (26.6 ± 25.9 mg/L and 0.1 ± 0.3 times/month) (p < .001). Rates of death with a functional graft were 30% and 0% in group 1 and 2 (p = .086). Biopsy-proven AA amyloidosis recurrence in the allograft was observed in 11 of 19 (58%) and seven of nine (78%) patients in group 1 and 2, respectively. Interestingly, glomerular amyloid deposition was not present in the vast majority of biopsies. De novo vasculer amyloid deposition was observed during treatment. CONCLUSION: IL-1 antagonist drug and colchicine combination almost completely prevented acute FMF attacks in kidney transplant patients with colchicine resistance. However, amyloid accumulation did not cease during IL-1 antagonist drug treatment.

The relationship between serum uric acid levels and development of obesity in living kidney donors after donor nephrectomy.

BACKGROUND: Hyperuricaemia plays a role in the pathogenesis of obesity and related metabolic disorders. The aim of this study to investigate the relationship between pre-donation serum uric acid (SUA) level and obesity development after nephrectomy in living kidney donors. METHODS: Living donors of kidney transplants between 1998 and 2019 were evaluated. Donors with less than 1 year of follow-up were excluded from the study. The participants were divided into two groups according to last control body mass index (BMI) (obese; ≥ 30 kg/m2 and nonobese; <30 kg/m2 ) and median baseline SUA level (<4.6 mg/dL and ≥4.6 mg/dL). RESULTS: In the included 240 donors, the mean follow-up was 50 ± 44 (12-216) months. The mean age was 47 ± 11 (19-82) years, and 46.6% of donors were male. At last control, the percentage of obese donors had increased significantly compared to pre-donation time (22.5% vs 33.8%; P < .001) and last control obese donors had both higher baseline SUA (5.1 ± 1.4 vs 4.5 ± 1.2; P < .01) and BMI (30.7 ± 2.6 vs 24.8 ± 3.0; P < .001). Cox regression analysis showed that there is an independent relationship between the baseline SUA level and development of obesity (odds ratio: 1.30 [CI; 1.12-1.50]; P < .001). In Kaplan-Meier analysis, the development of obesity was significantly higher in kidney donors with high SUA level. CONCLUSION: Living kidney donors (LKD) have a tendency to obesity after nephrectomy. Preoperative serum uric acid level gives important information in LKDs that it could foresee the development of obesity after donation.

Clinicopathologic features of single bone metastasis in breast cancer.

ABSTRACT: The most common site for metastasis in patients with breast cancer is the bone. In this case series, we investigated patients whose surgical and medical treatment for primary breast cancer was conducted at our center and first disease recurrence was limited to only 1 bone.We analyzed 910 breast cancer patients, 863 had no metastasis and 47 cases had a single bone metastasis ≥ 6 months after their first diagnosis. Demographic, epidemiological, histopathological and intrinsic tumor subtype differences between the non-metastatic group and the group with solitary bone metastases and their statistical significance were examined. Among established breast cancer risk factors, we studied twenty-nine variables.Three variables (Type of tumor surgery, TNM Stage III tumors and mixed type (invasive ductalcarsinoma + invasive lobular carcinoma) histology) were significant in multivariate logistic regression analysis. Accordingly, the risk of developing single bone metastasis was approximately 15 times higher in patients who underwent mastectomy and 4.8 and 2.8 times higher in those with TNM Stage III tumors and with mixed type (invasive ductal carcinoma + invasive lobular carcinoma) histology, respectively.In conclusion, the risk of developing single bone metastasis is likely in non-metastatic patients with Stage III tumors and possibly in mixed type tumors. Knowing this risk, especially in patients with mixed type tumors, may be instrumental in taking measures with different adjuvant therapies in future studies. Among these, treatment modalities such as prolonged hormone therapy and addition of bisphosphonates to the adjuvant treatments of stage III and mixed breast cancer patients may be considered.

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes.

BACKGROUND: In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). PATIENTS AND METHODS: In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. RESULTS: The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05). CONCLUSION: MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

The course of alterations in ureteral jet dynamics following kidney transplantation: a prospective observational cohort study.

OBJECTIVES: To prospectively investigate the alterations and normal ranges of ureteral jet dynamics after double-J-stent (DJS) removal in patients who underwent renal transplantation (RTx). METHODS: Patients who underwent RTx were prospectively evaluated between November 2017 and June 2018. After RTx, Doppler ultrasonography (D-US) was performed on all patients after DJS removal. Renal artery resistive index (RA-Ri), renal pelvis anterior-posterior diameter (RP-APD), pelvicalyceal system dilation (PCSD), and ureteral jet flow dynamics (maximum and average velocity; JETmax and JETave) were measured by D-US. Also, patients' demographics, estimated glomerular filtration rate (eGFR) levels, and acute rejection were investigated in the study. Patients were assessed two different times by D-US, about 6 and 12 weeks after DJS removal, and the two different measurements were compared with the Wilcoxon test and Chi-square test. RESULTS: A total of 25 patients were evaluated in the study. Nonobstructive PCSD rate (12% vs 8%), JETave (18.8 vs 12.9 cm/sec), and JETmax (29.2 vs 20 cm/sec) levels were significantly decreased (p values are 0.01, 0.010 and 0.014, respectively). In addition, monophasic and square pattern rates were significantly observed to increase over time (p=0.035); however, ureteral jet patterns were correlated between the two different D-US measurements (R=0.225, p=0.032). CONCLUSION: After RTx, dilation rate and ureteral jet flow velocities were significantly decreased, and monophasic and square JETpattern rates were significantly increased over time. Ureteral jet dynamics can provide useful information about the follow-up of peristaltic activity in the pelvic-ureteric system.

The course of alterations in ureteral jet dynamics following kidney transplantation: a prospective observational cohort study

SUMMARY OBJECTIVES To prospectively investigate the alterations and normal ranges of ureteral jet dynamics after double-J-stent (DJS) removal in patients who underwent renal transplantation (RTx). METHODS Patients who underwent RTx were prospectively evaluated between November 2017 and June 2018. After RTx, Doppler ultrasonography (D-US) was performed on all patients after DJS removal. Renal artery resistive index (RA-Ri), renal pelvis anterior-posterior diameter (RP-APD), pelvicalyceal system dilation (PCSD), and ureteral jet flow dynamics (maximum and average velocity; JETmax and JETave) were measured by D-US. Also, patients' demographics, estimated glomerular filtration rate (eGFR) levels, and acute rejection were investigated in the study. Patients were assessed two different times by D-US, about 6 and 12 weeks after DJS removal, and the two different measurements were compared with the Wilcoxon test and Chi-square test. RESULTS A total of 25 patients were evaluated in the study. Nonobstructive PCSD rate (12% vs 8%), JETave (18.8 vs 12.9 cm/sec), and JETmax (29.2 vs 20 cm/sec) levels were significantly decreased (p values are 0.01, 0.010 and 0.014, respectively). In addition, monophasic and square pattern rates were significantly observed to increase over time (p=0.035); however, ureteral jet patterns were correlated between the two different D-US measurements (R=0.225, p=0.032). CONCLUSION After RTx, dilation rate and ureteral jet flow velocities were significantly decreased, and monophasic and square JETpattern rates were significantly increased over time. Ureteral jet dynamics can provide useful information about the follow-up of peristaltic activity in the pelvic-ureteric system.

RESUMO OBJETIVOS Investigar prospectivamente as alterações e as variações normais da dinâmica do jato ureteral após a remoção do J-stent duplo (DJS) em pacientes submetidos a transplante renal (RTx). MÉTODOS Pacientes submetidos a RTx foram avaliados prospectivamente entre novembro de 2017 e junho de 2018. Após o RTx, o D-US foi realizado em todos os pacientes após a remoção do DJS. Índice de resistência da artéria renal (RA-Ri), diâmetro ântero-posterior da pelve renal (AP-DPR), dilatação do sistema pelvicaliceal (PCSD) e dinâmica do jato ureteral (velocidade máxima e média; JETmax e JETave) foram medidos por D-US. Além disso, a demografia dos pacientes, os níveis estimados de taxa de filtração glomerular (eGFR) e a rejeição aguda foram investigados no estudo. Os pacientes foram avaliados em dois momentos diferentes pelo D-US, cerca de 6 e 12 semanas após a remoção do DJS, e as duas medidas diferentes foram comparadas com o teste de Wilcoxon e o teste do qui-quadrado. RESULTADOS Um total de 25 pacientes foi avaliado no estudo. Taxa de PCSD não obstrutiva (12% vs. 8%), JETave (18,8 vs. 12,9 cm/seg) e JETmax (29,2 vs. 20 cm/seg), os níveis foram significativamente diminuídos (valores de p são 0,01, 0,010 e 0,014, respectivamente). Além disso, as taxas de padrão monofásico e quadrado foram significativamente observadas para aumentar ao longo do tempo (p=0,035); no entanto, padrões de jato ureteral foram correlacionados entre as duas diferentes medidas D-US (R=0,225, p=0,032). CONCLUSÃO Após o RTx, a velocidade de dilatação e as velocidades de fluxo do jato ureteral foram significativamente diminuídas e as taxas de JET padrão monofásico e quadrado foram significativamente aumentadas ao longo do tempo. A dinâmica do jato ureteral pode fornecer informações úteis sobre o acompanhamento da atividade peristáltica no sistema pélvico-ureteral.

Response to treatment in kidney transplant recipients with acute antibody-mediated rejection: A follow-up biopsy study
.

BACKGROUND: The aim of this study is to evaluate the efficacy of a treatment protocol for the management of acute antibody-mediated rejection (AAMR) and mixed-type rejection (MTR), both histopathologically and clinically. MATERIALS AND METHODS: Of the 362 cases undergoing kidney transplantation from January 2010 to January 2018, patients with AAMR or MTR in the first 3 months after transplantation were included. All patients had follow-up biopsy (Bx) after treatment. RESULTS: 33 (9.1%) patients had diagnosis of AMR. Mean follow-up was 35 ± 20 months. 28.5% of patients had poor clinical progression at the last follow-up. Of the 25 patients with functional grafts, the mean serum creatinine was 1.6 ± 0.6 mg/dL for live and 2.1 ± 1.0 mg/dL for deceased transplant recipients. In diagnostic biopsies, there were 61% MTR. In follow-up Bx, after treatment, both C4d positivity and the severity of rejection had decreased while the mean chronic allograft damage index (CADI) score and transplant glomerulopathy showed an increase. CONCLUSION: With effective antibody mediated rejection (AMR) therapy, renal function parameters were significantly improved. Histologically, improvement in tubulointerstitial inflammation may be responsible for this process. However, progressive chronic changes, particularly in the glomeruli, are noteworthy.